fundamental test a & b
a nurse is providing care to four clients. which of the following situations requires the nurse to complete an incident report? 1. a nurse tied a client's restraint straps to the moveable part of the bed frame. 2. an assistive personnel placed a surgical mask on a client who has tuberculosis before transporting her to radiology. 3. a nurse administers a medication to a client 30 min before the does is due. 4. a client who has an IV infusion pump receives an additional 250 ml of IV fluid.
a client who has an IV infusion pump receives an additional 250 ml of IV fluid. the nurse should complete an incident report if an IV infusion pump malfunctions to assist in compiling information for risk management to determine actions to take to prevent further similar incidents.
a nurse is caring for a client who reports pain. when documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? 1. I am having mild pain. 2. the pain is like a dull ache in my stomach 3. i notice that the pain gets worse after I eat 4. the pain make me feel nauseous.
the pain is like a dull ache in my stomach the client is describing the quality of the pain, which is how the pain feels in her own words.
a nurse is responding to a call light and finds a client lying on the bathroom floor. which of the following actions should the nurse take first? 1. check the client for injuries 2. move hazardous objects away fro the client 3. notify provider 4. ask the client to describe how she felt prior to the fall
1. the first action the nurse should take when using the nursing process is to assess the client for injuries.
a nurse is administering an otic medication to an older adult client. which of the following action should the nurse take to ensure that the medication reaches the inner ear? 1. press gently on the tragus of the client's ear. 2. pack a small piece of cotton deep into the client's ear canal. 3. move the clients' auricle down and back toward her head. 4. tilt the client head backward for 5 min.
press gently on the tragus of the client's ear. pressing gently on the tragus of the earl will help the medication get into the inner ear.
a nurse is assisting a client who is postoperative with the use of an incentive spirometer. into which of the following positions should the nurse place the client? 1. side-lying 2. supine 3. semi-fowler's 4. trendelenburg
semi-fowler's positioning the client in semi-fowler's position allows for maximum expansion of the lungs.
a nurse is caring for a client receiving fluid through a peripheral IV catheter. which of the following finding at the IV site should the nurse identify as infiltration? 1. purulent exudate 2. warmth 3. skin blanching 4. bleeding
skin blanching skin blanching, edema, and coolness at the IV site indicate infiltration
a nurse is preparing to administer an injection of an opioid medication to a client. the nurse draws out 1 ml of the medication from a 2 ml vial. which of the following actions should the nurse takE? 1. ask another nurse to observe the medication wastage. 2. notify the pharmacy when wasting the medication 3. lock the remaining medication in the controlled substances cabinet. 4. dispose of the vial with the remaining medication in a sharps container
ask another nurse to observe the medication wastage. a second nurse must be witness the disposal of any portion of a dose of a controlled substance.
a nurse is evaluation a client's use of a cane. which of the following actions should the nurse identify as an indication of correct use? 1. the top of the cane is parallel to the client's waist. 2. when walking, the client moves the cane 46 cm forward 3. the client holds the cane on the stronger side of her body. 4. the client moves her stronger limb forward with the cane.
the client holds the cane on the stronger side of her body the client should hold the cane on the stronger side of her body to increase support and maintain alignment.
a nurse is admitting a client who has influenza. which of the following types of transmission precautions should the nurse initiate? 1. droplet 2. airborne 3. contact 4. protective environment
1. droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis
a nurse is assessing an adult client who as been immobile for the past 3 weeks. the nurse should identify that which of the following finding requires further internvetion? 1. erythema on pressure point 2. lower-extremity pulse strength of 2+ 3. fluid intake of 3000 ml per day 4. a bowel movement every other day
1. erythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from further breakdown.
a nurse is performing a peripheral vascular assessment for a client. when placing the bell of the stethoscope on the client's neck, she hears the following sound. this sound indicates which of the following? (click on the audio button to listen to the clip.) 1. narrowed arterial lumen 2. distended jugular veins 3. impaired ventricular contraction 4. asynchronous closure of the aortic and pulmonic valves
1. narrowed arterial lumen arterial bruits are blowing sounds resulting from blood flowing through occluded or narrowed arteries.
a nurse is preparing to administer 0.5 ml of oral single-dose liquid medication to a client. which of the following action should the nurse take? 1. gently shake the container of medication prior to medication administration 2. transfer the medication to a medication cup 3. place the client in a semi-folwer's position prior to medication administration 4. verify the dosage by measuring the liquid before administering it
1. the nurse should gently shake the liquid medication to ensure the medication is mixed.
a nurse is administering IV fluid to an older adult client. the nurse should perform which priority assessment to monitor for adverse effect? 1. auscultate lung sounds 2. measure urine output 3. monitor blood pressure reading 4. monitor serum electrolyte levels
1. the priority assessment the nurse should make when using the airway, breathing, circulating approach to client care is auscultating lung sounds to monitor for fluid-volume excess, a complication of IV therapy. Manifestation of fluid volume excess include moist crackles heard in lung fiields, dyspnea, and shortness of breath
a nurse is reviewing protocol in preparation for suctioning secretions fro a client who has a new tracheostomy. which of the following action should the nurse plan to takE? 1. use a resuscitating bag with 80% oxygen prior to the precedure 2. select a suction catheter that is half the size of the lumen 3. place the end of the suction catheter in water-soluble lubricant 4. adjust the wall suction apparatus to a pressure of 170mm hg
2. the nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa.
a nurse is caring for a client who is reporting difficult falling asleep. which of the following measures should the nurse recommend? 1. drink a cup of hot cocoa before bedtime 2. exercise 1 hr before going to bed 3. use progressive relaxation technique at bedtime 4. reflect on the day's activity before going to bed
3. progressive relaxation promotes sleep by decreasing stress and reducing muscle tension.
a nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. which of the following actions should the nurse take? 1. place the client in a side-lying position 2. instill 15 mil of irrigation fluid into the catheter with each flush. 3. subtract the amount of irrigant used from the client's urine output. 4. perform the irrigation using 20 ml syringe
3. subtract the amount of irrigant used from the client's urine output the nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output.
a nurse is planning care to improve self-feeding for a client who has vision loss. which of the following interventions should the nurse include in the plan of care? 1. tell the client which food she should eat firt 2. provide small-handle utensils for the client 3. thicken liquid on the client's tray 4. use a clock pattern to describe food on the client's plate
4. describing the location of the food on the plate by using a clock pattern allows the client to have greater independence during meals
the nurse is caring for a client who has had his dient prescription changed to a mechnical soft diet. which of the following food items should the nurse remove from the client's breakfast tray? 1. tomato juice 2. banana 3. pancake 4. fried egg
4. eivdence-based practice indicate the nurse should remove the fried eggs from the client's tray. fried eggs are not a part of a mechanical soft diet. eggs that are poached or scrambled are a acceptable replacement for this item.
a nurse in a long-term care facility is planning to perform hygiene care for a new resident. which of the following assessment questions is the nurse's priority before beginning this procedure? 1. when do you usually bathe, in the morning or in the evening 2. do you prefer a bath or a shower 3. at what temperature do you prefer your bath water? 4. are you able to help with your hygiene care
4. the greater risk to the client's safety is an injury resulting fro an overestimation of the client's ability to help with hygiene care; therefore, the nurse's priority is to assess the client's ability to assist with her hygiene care.
a nurse is preparing to administer multiple medication to a client who has an enteral feeding tube. which of the following action should the nurse plan to take? 1. dissolve each medication in 5 ml of sterile water. 2. draw up medications together in the syringe. 3. push the syringe plunger gently when feeling resistance. 4. flush the tube with 15 ml of sterile water.
flush the tube with 15 ml of sterile water. the nurse should flush the feeding tube with 30-60 ml of sterile water following the administration of the last medication.
a charge nurse is discussing the responsibility of nurses caring for clients who have a clostridium difficle infection. which of the following information should the nurse include in the teaching? 1. assign the client to a room with a negative flow system 2. use alcohol-based hand sanitizer when leaving the client's room 3. clean contaminated surfaces in the client's room with a phenol solution 4. have family members wear a gown and gloves when visiting.
have family member wear a gown and gloves when visiting nurse are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of clostridium difficile spores. caregivers must also wear gowns and gloves
a nurse is assessing an older adult client's risk for falls. which of the following assessment should the nurse use to identify te client's safety needs? select all lacrimal apparatus pupil clarity appearance of bulbar conjunctivae visual fields visual acuitiy
pupil clarity - cloudy pupills mean that the client has cataracts. this make his vision cloudy and creates halo around the lights, which can increase his risk for falls because he cannot see items in his path clearly. visual field - the nurse should use a finger to test the client's peripheral vision by moving it out of range and then back into his visual field to determine when he sees the finger. if the client has a visual field impairment, he is at risk for falls because he might not see objects outside his central vision and trip over them or bump into them and fall visual acuity - the nurse should use a Snellen chart to assess distance vision and a handheld card to assess near vision. if the client wears glasses, he should wear them during the assessment. if the client has a vision impairment, he is at risk for falls because he might not see object in his pathway and trip over them or bump into them and fall.
a nurse is caring a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take? a. discuss the risk factors for colon cancer. 2. focus teaching on what the client will need to do in the future to manage his illness. 3. provide the client with written information about the phases of loss and grief. 4. reassure the client that this is an expected response to grief
reassure the client that this is an expected response to grief. during the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and ensure him that this is an expected reaction to an cancer diagnosis.
a nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. to prevent self-injury, which of the following action should the nurse take when lifting this object? 1. bend at the waist. 2. keep his feet closer together. 3. use his back muscle for lifting. 4. stand close to the cabinet when lifting it
stand close to the cabinet when lifting it. this action keeps the cabinet close to the nurse's center of gravity and decrease back strain from horizontal reaching.
